New Client Forms

Expect personalized, compassionate care as you begin your journey with Dr. Cavell, dedicated to understanding and addressing your unique needs. If you prefer to print your forms instead, download here and email them to emilycavellphd@gmail.com or bring them to your first appointment.

Credit Card Authorization

Name

First Name

Last Name

Name as it appears on card

First Name

Last Name

Type of Card

Account #

Expiration Date

Security Code #

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization

This form is used to register credit card information with Dr. Emily Cavell, allowing you to pay for services rendered. Your credit card information will be kept secured and confidential.

By submitting this form, the undersigned agrees to the following

1. I hereby authorize Dr. Emily Cavell to make charges upon the credit card for any applicable fees for services I receive. 2. I understand that this form will be kept on file and will remain in effect until revoked in writing and/or the expiration date of the card has passed. I understand that it is my responsibility to complete a new credit card authorization form when the credit card has been renewed, revoked, cancelled or misplaced. 3. I understand that in the event any charge against this account is denied, I will be notified immediately to make payment in cash, money order, or certified check for any outstanding balance. 4. I understand that I can remove this authorization in writing at any time if I prefer to pay in cash, money order, or check.

I Agree

Signature

Write your name for digital signature

First Name

Last Name

Date

YYYY

Initial Consultation

Name

First Name

Last Name

Date

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May I email you?

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Preferred Contact Number

Emergency Contact

First Name

Last Name

Emergency Contact Number

(###)

###

####

Emergency Contact Relationship

Primary Care Physician

Phone

(###)

###

####

Other Treatment Provider

Phone

(###)

###

####

Have you been in therapy before?

With Whom

First Name

Last Name

Phone

(###)

###

####

May I contact these providers to discuss your care?

Signature

If yes, write your name for digital signature and date

First Name

Last Name

Date

YYYY

New Client Forms

Expect personalized, compassionate care as you begin your journey with Dr. Cavell, dedicated to understanding and addressing your unique needs. If you prefer to print your forms instead, download here and email them to emilycavellphd@gmail.com or bring them to your first appointment.

**Take Charge of Your Life**

Emily Cavell, PhD

Clinical Psychologist in Los Angeles

Contact

Location